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While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion
site. What interventions should the nurse implement? -answer- Promptly remove the arterial catheter
from the radial artery.
A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To
differentiate the vascularsource of the intracranial bleeding, which finding should the nurse monitor?
-answer- Rapid onset of decreased level of consciousness.
When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to
treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge
teaching plan? -answer- Report any signs of cloudy urine output.
After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching,
what action should the nurse take? -answer- Apply light pressure over the area.
The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture.
What action should the nurse take? -answer- Reposition the restraint tie onto the bedframe.
A female client with acute respiratory distresssyndrome (ARDS) is chemically paralyzed and sedated
while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants
immediate intervention by the nurse? -answer- Diminished lef t lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required
immediate chest tube insertion to re-inflate the lung.
The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological
events in orders of occurrence. (Place the first event on top and the last on the bottom) -answer- Arterial
endothelium injury causes inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cellsrelease growth factors for smooth muscle cells
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